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Thuong-Thuong Nguyen MD
Basics
Description
Vaginal epithelium thinning secondary to estrogen deficiency, resulting in
vaginal dryness and inflammation
Age-Related Factors
Atrophic vaginitis is most common in menopausal and postmenopausal
women.
May also be present postpartum in a woman who is breastfeeding
Epidemiology
1040% of postmenopausal women have symptoms of atrophic vaginitis.
Risk Factors
Menopause, either natural or surgical (oophorectomy): Decline in endogenous
estrogen
Premenopause:
o
Immunologic disorder
Smoking
No vaginal delivery
Pathophysiology
Circulating estrogen, mainly estradiol, helps maintain vaginal epithelium
elasticity and moistness by stimulating the production of collagen and
hyaluronic acid, respectively.
Estrogen stimulates nonkeratinized stratified squamous epithelium to thicken,
form rugae, and fill with glycogen:
o
Associated Conditions
The genital and urinary tract share a common embryologic origin. The urethral
epithelium, bladder, pelvic muscle floor, and pelvic fascia are also estrogen
dependent. Dysuria, hematuria, urinary frequency may occur.
Diagnosis
Signs and Symptoms
The majority of women with mild to moderate vaginal atrophy are
asymptomatic.
Symptoms of atrophic vaginitis generally appear only after estrogen levels
have been low for an extended period.
Early on, women may notice a slight decrease in vaginal lubrication upon
arousal, which is one of the 1st signs of estrogen insufficiency.
History
Menstrual history
Last menstrual period or final menstrual period
Smoking
Review of Systems
Special attention to GU symptoms
Physical Exam
General:
External genitalia: Loss of labial and vulvar fullness, sparsity of pubic hair,
dryness of labia, vulvar lesions, vulvar dermatoses:
o Areas of microtrauma or fissures at peri-introital area and posterior
fourchette may be seen at colposcopy, if indicated
o
Introital stenosis
Urethral:
o
Urethral polyps
Ecchymoses
Vaginal:
o
Rectocele
Cystocele
Tests
Lab
Serum hormone levels are generally not helpful to assess for menopause, as
FSH can wax and wane during menopausal transition.
A low level of circulating estradiol may be present, but is not clinically useful
(25 pg/mL).
Pap smear can confirm the presence of urogenital atrophy.
Imaging
TVUS of the uterine lining that demonstrates a thin endometrium measuring between
4 and 5 mm signifies loss of adequate estrogenic stimulation.
Differential Diagnosis
Infection
Candidiasis
Bacterial vaginosis
Trichomoniasis
Metabolic/Endocrine
POF (ovarian insufficiency)
P.203
Immunologic
Contact irritation or reaction to perfumes, powders, deodorants, panty liners, perineal
pads, soaps, spermicides, lubricants, tight-fitting or synthetic clothing
Other/Miscellaneous
Vulvar lichen sclerosus
Vulvar vestibulitis
Treatment
General Measures
Moisturizers and lubricants may be used in conjunction with estrogen therapy
or as alternative treatment:
o Women who choose not to take HRT, have medical contraindications,
or experience hormonal side effects.
o
Special Therapy
Complementary and Alternative Therapies
Insufficient evidence to support the use of DHEA-containing vaginal creams
Medication (Drugs)
Estrogen replacement:
o Restores normal pH levels; thickens and revascularizes the epithelium
o
Estrogen-sensitive tumors
Breast tenderness
Venous thromboembolism
Followup
Disposition
Issues for Referral
Urogynecology for urinary symptoms or pelvic organ prolapse
Prognosis
Most women get relief of symptoms with vaginal formulations of estrogen.
Systemic estrogens may require the addition of vaginal estrogen formulations.
Nonestrogen therapies are less effective for most women than estrogen.
Patient Monitoring
Assess compliance (frequency of use) and need for progestin therapy in women on
estrogen therapy:
TVUS may be helpful in assessing endometrial proliferation.
Bibliography
Bachmann GA, et al. Diagnosis and treatment of atrophic vaginitis. Am Fam Phys.
2000;61:3090.
Ballagh SA. Vaginal hormone therapy for urogenital and menopausal symptoms.
Semin Reprod Med. 2005;23(2):126140.
Botsis D, et al. Transvaginal sonography in postmenopausal women treated with lowdose estrogens locally administered. Maturitas. 1996;23:4145.
Cardozo L, et al. Meta-analysis of estrogen therapy in the management of urogenital
atrophy in postmenopausal women: Second report of the Hormones and Urogenital
Therapy Committee. Obstet Gynecol.1998;92:722.
Castelo-Branco C, et al. Management of post-menopausal vaginal atrophy and
atrophic vaginitis. Maturitas. 2005;52(Suppl 1):S46.
Leiblum S, et al. Vaginal atrophy in the postmenopausal woman: The importance of
sexual activity and hormones. JAMA. 1983;249:2195.